Poisoning with the recreational drug paramethoxyamphetamine ("death")

Supraventricular tachycardia with the use of phentermine: case report and review of literature

Case: A 34-year-old woman with no significant past medical history presented to the hospital with sudden onset of palpitations with associated dyspnea and chest discomfort. She denied any similar previous episodes. Initial electrocardiogram (EKG) was consistent with a short R-P interval supraventricular tachycardia (SVT). Her transthoracic echocardiogram (TTE) revealed no structural abnormalities, TSH levels were normal, and urine drug screen was negative for any recreational drugs. However, the patient had been taking phentermine for weight loss.Discussion: The exact mechanism is not clear; however, we postulate that the sympathomimetic effects of phentermine likely contribute to SVT induction through enhanced AV nodal conduction or increased atrial ectopy. Conclusions: The only medication she was taking at home was phentermine, and the palpitations did not recur after discontinuation of the drug during follow-up. It is important to collect a thorough medication history when patients present with AV nodal reentrant tachycardia (AVNRT) or other SVT.

Music festival attendees' illicit drug use, knowledge and practices regarding drug content and purity: a cross-sectional survey

BACKGROUND

Drug checking is a harm reduction strategy which allows users to check the content and purity of illicit drugs. Although drug checking has been trialled internationally, with demonstrated value as a harm reduction and health promotion strategy, the use of such services in Australia remains a contentious issue. This study aimed to investigate the proportion and patterns of illicit drug use among young people, their attitudes towards drug checking at festivals and the potential impact of drug checking on intended drug use behaviour.

METHODS

The survey was conducted at a major Australian music festival in 2016. Data was collected from a sample of festival attendees (n = 642) aged between 18 and 30 years. A descriptive analysis of the data was performed.

RESULTS

Nearly three-quarters (73.4%) of participants reported that they had used illicit drugs in the past 12 months, most commonly cannabis (63.9%) and ecstasy (59.8%). A large proportion of participants believed 'somewhat' or 'a lot' that drug checking services could help users seek help to reduce harm (86.5%) and that drug checking services should be combined with harm reduction advice (84.9%). However, two thirds of the participants agreed 'somewhat' or 'a lot' that drug sellers may use this service as a quality control mechanism (68.6%). Approximately half (54.4%) indicated they would be highly likely and a third (32.7%) would be somewhat likely to utilise free drug checking services should they be available at music festivals. When asked whether the results of drug checking would influence their drug use behaviour, participants reported that they would not take substances shown to contain methamphetamine (65.1%), ketamine (57.5%) or para-methoxyamphetamine (PMA) (58.4%).

CONCLUSION

The majority of festival attendees aged 18-30 participating in this study reported a history of illicit drug use and were in favour of the provision of free drug checking at festivals. A considerable proportion reported that the results of drug checking would influence their drug use behaviour. The findings of this study can contribute to the debate regarding whether drug checking services could potentially play a major role in harm reduction and health promotion programming for young people attending festivals.

The Non-Peptide Arginine-Vasopressin v1a Selective Receptor Antagonist, SR49059, Blocks the Rewarding, Prosocial, and Anxiolytic Effects of 3,4-Methylenedioxymethamphetamine and Its Derivatives in Zebra Fish

3,4-Methylenedioxymethamphetamine (MDMA) and its derivatives, 2,5-dimethoxy-4-bromo-amphetamine hydrobromide (DOB) and para-methoxyamphetamine (PMA), are recreational drugs whose pharmacological effects have recently been attributed to serotonin 5HT_2A/C receptors. However, there is growing evidence that the oxytocin (OT)/vasopressin system can modulate some the effects of MDMA. In this study, MDMA (2.5-10 mg/kg), DOB (0.5 mg/kg), or PMA (0.005, 0.1, or 0.25 mg/kg) were administered intramuscularly to adult zebra fish, alone or in combination with the V_1a vasopressin antagonist, SR49059 (0.01-1 ng/kg), before carrying out conditioned place preference (CPP), social preference, novel tank diving, and light-dark tests in order to evaluate subsequent rewarding, social, and emotional-like behavior. The combination of SR49059 and each drug progressively blocked: (1) rewarding behavior as measured by CPP in terms of time spent in drug-paired compartment; (2) prosocial effects measured on the basis of the time spent in the proximity of a nacre fish picture; and (3) anxiolytic effects in terms of the time spent in the upper half of the novel tank and in the white compartment of the tank used for the light-dark test. Antagonism was obtained at SR49059 doses which, when given alone, did not change motor function. In comparison with a control group, receiving vehicle alone, there was a three to five times increase in the brain release of isotocin (the analog of OT in fish) after treatment with the most active doses of MDMA (10 mg/kg), DOB (0.5 mg/kg), and PMA (0.1 mg/kg) as evaluated by means of bioanalytical reversed-phase high-performance liquid chromatography. Taken together, these findings show that the OT/vasopressin system is involved in the rewarding, prosocial, and anxiolytic effects of MDMA, DOB, and PMA in zebra fish and underline the association between this system and the behavioral alterations associated with disorders related to substance abuse.

Medicolegal aspects of PMA-related deaths

Unlike amphetamine, amphetamine-like substances accessible on the drug market are less expensive and more easily available; they also produce hallucinogenic effects expected by the users. Such properties render them more attractive as compared to amphetamine. On the other hand, the knowledge of the toxicity of these compounds is very limited, what in consequence generates problems that create ever-expanding research areas, including analytical, clinical and medicolegal issues, thus leading to development of systemic databases. An example here is paramethoxyamphetamine (PMA), which appeared on the drug market in recent years as a result of creative inventiveness of producers of psychoactive substances, who aimed at PMA replacing the popular ecstasy (MDMA) as a less expensive and more available product. It is more potent than MDMA, but has a slower onset of action, which encourages users to take more. The problem is illustrated in the present paper by three fatal cases involving PMA, which were comprehensively investigated taking into consideration case histories, pathological and toxicological findings obtained with the use of LC-MS-MS method. In blood samples taken from all the three victims, very high concentrations of PMA were found (in the range of 10-27mg/L) and thus the cause of deaths was determined as overdoses of PMA with the underlying mechanism of acute cardiorespiratory failure.

Effect of amphetamine on corrected-QT interval change during methadone maintenance treatment in Taiwan: a prospective cohort study

INTRODUCTION AND AIMS

Previous studies have suggested that methadone is associated with prolonged corrected-QT (QTc) interval, but published prospective research studies in this area are relatively scarce. This study investigates QTc interval change among methadone maintenance patients and possible associated risk factors. One of the aims is to explore the effect of amphetamines.

DESIGN AND METHODS

This prospective cohort study with six-month follow up assesses the effect of methadone on QTc interval among a sample (n = 170) of heroin users in a methadone maintenance treatment program in Taiwan. Demographic data, substance use history, medical history and laboratory studies were collected at study enrollment. Twelve-lead electrocardiograms were performed for all participants both at study enrollment and six months later.

RESULTS

The median daily methadone dose was 41 mg. A mean increase of QTc interval (17.1 ms, SD = 50.0, P < 0.001) was found at six-month follow up. QTc interval prolongation in the sample at baseline was 2.9%, and at six months was 12.4%. A positive correlation was found between comorbid amphetamine use frequency in the past month and QTc interval change. Methadone dose was not associated with QTc change.

DISCUSSION AND CONCLUSIONS

An increase of mean QTc interval was found among methadone maintenance patients at six-month follow up. Electrocardiogram monitoring should be performed among patients who are at risk of frequently using amphetamines during methadone maintenance treatment.

Teenage toxins: recreational poisoning in the adolescent

Adolescents are experimenting with recreational drugs on a regular basis, particularly at social gatherings such as parties, raves and mass events. A combination of reduced fluid intake, physical activity and drug-induced hyperthermia leads to complications such as heat stroke, delirium and potentially death. The clinician needs to be aware of the variety of pharmacologically active substances available in the recreational marketplace in order to diagnose and manage these patients. Recreational misadventure, because of incorrect dosage or mixing multiple substances, is a common reason for teenagers presenting to hospital with toxidromes. Death from club drug overdose is more likely to be associated with suicidal intent, related risky behaviour and trauma, as well as the inherent toxicity of the drug itself. Although many teenagers are concerned about 'drink spiking' with club drugs, the most common agent causing drink spiking incidents is ethanol.

The PMMA epidemic in Norway: comparison of fatal and non-fatal intoxications

During a 6 month period (July 2010-January 2011) we observed 12 fatal intoxications and 22 non-fatal cases related to the drug paramethoxymethamphetamine (PMMA) in Norway (4.8 mill inhabitants). This toxic designer drug, also known as "Death", is occasionally found in street drugs offered as "ecstasy" or "amphetamine". The present study aimed to evaluate the cause of death, and to compare the PMMA blood concentrations in fatal and non-fatal cases. Methods for identification and quantification of PMMA are presented. The median age of fatalities was 30 years (range 15-50) with 67% males; in non-fatal cases 27 years (20-47) with 86% males. In the 12 fatalities, the median PMMA blood concentration was 1.92 mg/L (range 0.17-3.30), which is in the reported lethal range of 0.6-3.1 mg/L in peripheral blood and 1.2-15.8 mg/L in heart blood. In the 22 non-fatal cases, the median PMMA concentration was 0.07 mg/L (range 0.01-0.65). Poly-drug use was frequent both in fatal and non-fatal cases. The PMA concentrations ranging from 0.00 to 0.26 mg/L in both groups likely represented a PMMA metabolite. Three fatalities were attributed to PMMA only, six to PMMA and other psychostimulant drugs, and three to PMMA and CNS depressant drugs, with median PMMA concentrations of 3.05 mg/L (range 1.58-3.30), 2.56 (1.52-3.23) and 0.52 mg/L (0.17-1.24), respectively. Eight victims were found dead, while death was witnessed in four cases, with symptoms of acute respiratory distress, hyperthermia, cardiac arrest, convulsions, sudden collapse and/or multiple organ failure. In summary, all fatalities attributed to PMMA had high PMMA blood concentrations compared to non-fatal cases. Our sample size was too small to evaluate a possible impact of poly-drug use. A public warning is warranted against use and overdose with illegal "ecstasy" or "speed" drugs.

Severe paramethoxymethamphetamine (PMMA) and paramethoxyamphetamine (PMA) outbreak in Israel

CONTEXT

Paramethoxymethamphetamine (PMMA) is a hallucinogenic synthetic substituted amphetamine that was not included in the Israeli Controlled Substance Act (CSA).

OBJECTIVE

To report a severe PMMA and paramethoxyamphetamine (PMA) outbreak.

PATIENTS AND METHODS

The Israeli national forensic toxicology laboratory analyzes the body fluids of unnatural deaths by means of screening immunoassays and chromatographic confirmation and quantification. Samples are referred to this laboratory by the Israeli Forensic Medicine Institute and by hospitals following consultation with the Israel Poison Information Center. The forensic toxicology laboratory began determining PMMA and PMA in February 2007. In all fatal cases with a positive immunoassay screen for amphetamines, a chromatographic analysis of PMA and PMMA was performed. The laboratory and demographic data of consecutive patients in whom PMMA or PMA were detected, were collected during 1 year and subjected to descriptive analysis.

RESULTS

Of 108 fatal cases with a positive screen for amphetamines, 32 were confirmed. Twenty-four of the 32 cases tested positive for PMMA and PMA--age 27 ± 5 years, 79.2% males, post mortem whole blood PMMA and PMA concentrations 0.35 ± 0.24 and 2.72 ± 1.67 mcg/mL, respectively. Co-exposures were detected in 17 (70.8%) fatalities; including methylenedioxymethamphetamine, methylenedioxyamphetamine, cocaine, cannabinoids, cathinone derivatives, ephedrine/pseudoephedrine, opiates, and ethanol. In addition, five non-fatal male cases were identified; age 32 ± 5 years, four had co-exposures to cocaine, cathinone derivatives, and cannabinoids. These findings led to the inclusion of PMMA in the CSA in July 2007, resulting in only three more fatalities in the following year.

DISCUSSION

We report an outbreak of PMMA and PMA poisoning resulting in 24 fatalities, and the post mortem whole blood and urine concentrations of these two compounds. PMA was probably the result of PMMA metabolism. Stimulant co-exposures may have contributed to the severity of the poisoning.

CONCLUSION

Forensic laboratory and poison center co-operation is important in identifying a new drug of abuse.

Toxicologists in public health--Following the path of Louis Roche (based on the Louis Roche lecture "An accidental toxicologist in public health", Bordeaux, 2010)

BACKGROUND

The global burden of clinical toxicology suggests a natural partnership with public health. This article reflects the content of a Louis Roche lecture given in 2010. HISTORICAL CONTEXT: Our practice and research in clinical toxicology has evolved from clinical cases to toxico-epidemiology to public health. This evolution in practice was initially unplanned but gained momentum and impact as we placed it more formally in a public health framework. This perspective is implicit in Louis Roche's call to "examine all aspects of the poisoning problem" and still provides a valuable starting point for any clinical toxicologist.

DISCUSSION

Clinical toxicology has always had a patient centered focus but its greatest successes have been related to public health interventions. Our early failures and later success in pubic health toxicology correlated with our understanding of the importance of partnerships outside our field. The most rapid dissemination and implementation of information derived from research occur through apriori partnerships with other agencies and international partners.

CONCLUSION

Addressing both local and global need has a number of bilateral synergies. Repositioning clinical toxicology into a public health framework increases access to strategic partnerships, research funds, and policy implementation while still addressing questions that are important to clinical practice.

Bioanalysis of new designer drugs

Since the late 1990s the illicit drug market has undergone considerable change: along with the traditional drugs of abuse that still dominate, more than 100 psychotropic substances designed to bypass controlled substances legislation have appeared and led to intoxications and fatalities. Starting from the huge class of phenylalkylamines, containing many subgroups, the spectrum of structures has grown from tryptamines, piperazines, phenylcyclohexyl derivates and pyrrolidinophenones to synthetic cannabinoids and the first synthetic cocaine. Due to the small prevalence and high number of unknown substances, the detection of new designer drugs is a challenge for clinical and forensic toxicologists. Standard screening procedures might fail because a recently discovered or yet unknown substance has not been incorporated in the library used. Nevertheless, many metabolism studies, case reports, screening methods and substance-profiling papers concentrating on single compounds have been published. This review provides an overview of the developed bioanalytical and analytical methods, the matrices used, sample-preparation procedures, concentration of analytes in case of intoxication and also gives a résumé of immunoassay experiences. Additionally, six screening methods for biological matrices with a larger spectrum of analytes are described in more detail.

Amphetamine-associated seizures: clinical features and prognosis

Forty-four patients presenting with first-ever seizure within 24 h of illicit use of amphetamine or related analogs (amphetamine-associated seizures, AAS) were identified over 8 years. Patients with AAS were compared to control groups of other first-ever seizure patients (provoked n = 126 and unprovoked n = 401). Cumulative probability of recurrence was calculated using Kaplan-Meier analysis. Seizure recurrence and development of epilepsy were less likely in patients with AAS compared to provoked or unprovoked controls. Forty percent of patients with AAS had clinical risk factors for epilepsy, epileptiform abnormalities on electroencephalography (EEG), or an epileptogenic lesion on neuroimaging. Sleep deprivation was more frequently present in those with AAS. AAS likely relate to an intrinsic proconvulsant effect of these drugs combined with patient susceptibility and environmental factors.

The Health Effect of Psychostimulants: A Literature Review

Prevalence of psychostimulant use is high, and raising in several countries. Nicotine is the legal stimulant causing the most important public health impact. Cocaine ranks among the most used illicit substances after cannabis. Stimulant medications are frequently misused. Psychostimulants can lead to addiction, have physical, psychological and social health consequences and can induce a great disease burden. The aim of the present article is to provide a literature review on the health effects of stimulants as potential drugs of abuse. It will cover essentially cocaine, amphetamines and its derivatives (including methamphetamines and 3-4-methylenedioxymethamphetamine, ecstasy), nicotine, caffeine and khat, and touch upon the issues of prescribed substances (anti-depressants, weight control medications, attention-deficit hyperactivity disorder medications, hypersomniac disorder). Their pharmacology, addictive potential, health consequences and treatment will be discussed. We used Medline for the literature review from 1990 to the date of this review, and mention the findings of human and animal studies (the latter only if they are of clinical relevance).

Rhabdomyolysis in MDMA intoxication: a rapid and underestimated killer. "Clean" Ecstasy, a safe party drug?

BACKGROUND

Ecstasy is a popular drug among young adults. It is often thought to be safe. The dose of methylenedioxymethamphetamine (MDMA) in a tablet of Ecstasy varies greatly, and there is also a difference in individual response to a dose of MDMA.

OBJECTIVES

To increase the awareness of potential mortality in MDMA use.

CASE REPORT

We report the case of a patient with a lethal intoxication after pure MDMA intoxication. The serum toxicology screening showed an elevated level of MDMA (1.5 mg/L) but no other amphetamines or other drugs.

CONCLUSIONS

The cause of death was a rapidly evolving hyperkalemia due to rhabdomyolysis. There is still a need to educate the public about the dangers of this so-called "safe" party drug.

Cardiac arrest in the setting of diet pill consumption

The obesity epidemic currently plaguing the United States has spurred the development of a vast number of drugs to assist in the battle against obesity and its associated complications. The need to loose weight often causes patients to loose sight of or even ignore the serious side effects of some of the most widely used weight-loss medications. Here we present the case of ventricular tachycardia/fibrillation arrest in an otherwise healthy 48-year-old woman who was taking no medications other than phentermine, a common appetite suppressant that functions as a central nervous system stimulant through activation of the noradrenergic pathway of the sympathetic nervous system.

Potentiation of 3,4-methylenedioxymethamphetamine-induced 5-HT release in the rat substantia nigra by clorgyline, a monoamine oxidase A inhibitor

1. It is well established that the commonly used recreational drugs 3,4-methylenedioxymethamphetamine (MDMA, 'ecstasy') and para-methoxyamphetamine (PMA) facilitate the release and prevent the reuptake of 5-hydroxytryptamine (5-HT, serotonin). Although these drugs have similar potencies for their abilities to increase the release and inhibit the re-uptake of 5-HT, PMA has greater potency as an inhibitor of monoamine oxidase (MAO)-A. 2. The present study compared the abilities of PMA and MDMA to increase extracellular 5-HT concentrations in animals with functional MAO-A and when MAO-A activity was inhibited by clorgyline. 3. Samples of extracellular fluid from rat substantia nigra were collected using microdialysis and then analysed for 5-HT and 5-hydroxyindol acetic acid (5-HIAA) by high-performance liquid chromatography coupled with electrochemical detection. The 5-HT-mediated effects on body temperature and behaviour were also recorded. Rats were pretreated with saline or 10 mg/kg, i.p., clorgyline and, 24 h later, injected with 10 mg/kg MDMA, PMA or saline. 4. Both MDMA and PMA produced significant increases in extracellular 5-HT concentrations (482 +/- 83 and 726 +/- 287%, respectively; P < 0.05). Rats treated with PMA and MDMA displayed significantly increased 5-HT-related behavours (P < 0.05). Furthermore, only MDMA was capable of producing additional significant increases in 5-HT concentrations (1033 +/- 131%; P < 0.01) when coadministered with clorgyline. 5. The results of the present study suggest that PMA and MDMA are similar in their abilities to increase extracellular 5-HT levels in animals with functional MAO-A activity. However, coadministration of these substituted amphetamines with an MAO-A inhibitor causes significant potentiation in the ability to increase extracellular levels of 5-HT for MDMA, but not PMA.

Pharmacological and behavioral determinants of cocaine, methamphetamine, 3,4-methylenedioxymethamphetamine, and para-methoxyamphetamine-induced hyperthermia

RATIONALE

Cocaine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA, ecstasy), and para-methoxyamphetamine (PMA) disrupt normal thermoregulation in humans, with PMA being associated with more severe cases of hyperthermia. Harm minimization advice on how to prevent overheating depends on appropriate thermoregulatory behavior by drug users.

OBJECTIVES

The purpose of the current study was to establish dose-response relationships for the effects of a number of commonly used illicit stimulants and investigate the behavioral response to increased core temperature.

MATERIALS AND METHODS

Sprague-Dawley rats with telemetry implants were administered either saline or 4, 12, 26, 40 or 80 micromol/kg of cocaine, methamphetamine, MDMA, or PMA and confined to an ambient temperature of 30 degrees C for 30 min, before being able to choose their preferred temperature on a thermally graded runway (11-41 degrees C).

RESULTS

The increased core temperature caused by administration of cocaine, methamphetamine, and MDMA treatment led to the animals seeking the cool end of the runway to correct their core temperature, although this did not occur in PMA-treated rats. The order of potency for increasing core temperature was methamphetamine >PMA = MDMA>cocaine. This differed to the slopes of the dose-response curves where MDMA and PMA showed the steepest slope for the doses used followed by methamphetamine then cocaine.

CONCLUSIONS

These results suggest that behavioral aspects of thermoregulation are important in assessing the potential of individual drugs to cause harmful increases in core temperature.

The effects of co-administration of 3,4-methylenedioxymethamphetamine (“ecstasy”) or para-methoxyamphetamine and moclobemide at elevated ambient temperatures on striatal 5-HT, body temperature and behavior in rats

We have recently demonstrated that co-administration of 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") with the reversible monoamine oxidase type A (MAO-A) inhibitor moclobemide at an ambient temperature of 22 degrees C significantly increases striatal 5-HT outflow and 5-HT-mediated behaviors. In the present study, using microdialysis, we examined the effects of co-administration of MDMA or para-methoxyamphetamine (PMA) with moclobemide on striatal 5-HT outflow at the elevated ambient temperatures of 30 degrees C. Samples were collected every 30 min for 4 h and analyzed by high-performance liquid chromatography assay with electrochemical detection (HPLC-ED). 5-HT-mediated effects on body temperature and behavior were also recorded. Rats were treated with either saline or 20 mg/kg (i.p.) moclobemide, followed by 10 mg/kg (i.p.) MDMA, 10 mg/kg (i.p.) PMA or saline 60 min later. Both MDMA and PMA produced significant increases in 5-HT outflow (370% peak and 309% peak, respectively, P<0.05). MDMA and PMA significantly increased body temperature (+2.0 degrees C and +2.1 degrees C, respectively, P<0.01) and drug-related behaviors (P<0.05). When MDMA or PMA was co-administered with moclobemide, additional significant increases were seen in 5-HT outflow (850% peak, P<0.01 and 1450% peak, P<0.001, respectively) and only MDMA showed additional significant increase in body temperature (+5.0 degrees C, P<0.001). No additional increases were seen in behavioral activity. When moclobemide was co-administered with MDMA, sustained increases in body temperature were recorded that were significantly higher than with MDMA alone and such increases were not observed in our previous study at normal room temperature. Our results suggest greater risk of MDMA-induced adverse effects on body temperature regulation, compared with PMA, when used in combination with moclobemide at elevated ambient temperatures.

In vivo analysis of serotonin clearance in rat hippocampus reveals that repeated administration of p-methoxyamphetamine (PMA), but not 3,4-methylenedioxymethamphetamine (MDMA), leads to long-lasting deficits in serotonin transporter function

p-Methoxyamphetamine (PMA) has been implicated in fatalities as a result of 'ecstasy' (MDMA) overdose worldwide. Like MDMA, acute effects are associated with marked changes in serotonergic neurotransmission, but the long-term effects of PMA are poorly understood. The aim of this study was to determine the effect of repeated PMA administration on in vitro measures of neurodegeneration: serotonin (5-HT) uptake, 5-HT transporter (SERT) density and 5-HT content in the hippocampus, and compare with effects on in vivo 5-HT clearance. Male rats received PMA, MDMA (4 or 15 mg/kg s.c., twice daily) or vehicle for 4 days and 2 weeks later indices of SERT function were measured. [(3)H]5-HT uptake into synaptosomes and [(3)H]cyanoimipramine binding to the SERT were significantly reduced by both PMA and MDMA treatments. 5-HT content was reduced in MDMA-, but not PMA-treatment. In contrast, clearance of locally applied 5-HT measured in vivo by chronoamperometry was only reduced in rats treated with 15 mg/kg PMA. The finding that 5-HT clearance in vivo was unaltered by MDMA treatment suggests that in vitro measures of 5-HT axonal degeneration do not necessarily predict potential compensatory mechanisms that maintain SERT function under basal conditions.

Fatal amphetamine-associated cardiotoxicity and its medicolegal implications

Amphetamines are popular drugs of abuse, particularly among youngsters and at dance scenes. Cardiotoxicity (manifested as cardiomyopathy, acute myocardial infarction/necrosis, heart failure, or arrhythmia) after the recreational (mis)use of amphetamine and its synthetic derivatives has been documented but is rather rare. Amphetamine-related cardiac fatalities are even more rare. We present 6 cases of young persons who died unexpected after the chronic abuse of amphetamines. Death was not attributed to a lethal intoxication but to an acute myocardial necrosis, a right ventricle rupture, a cardiomyopathy, or an arrhythmia. Two of the deceased persons presented prior to their death to the emergency department, but their complaints were not considered (probably due to their young age) to be of cardiac origin. One case was a sport-related fatality where medical screening failed to identify the underlying cardiac pathology or the amphetamine abuse, and 1 case was a so-called idiopathic dilated cardiomyopathy where substance abuse was not considered by the treating physician. We think that amphetamine-associated cardiotoxicity is a rare but probably genuine entity that should be considered both in forensic and clinical/emergency medicine because of its potential medicolegal implications.

Ecstasy—deadly risk even outside rave parties

Fatalities due to 3,4-methylenedioxymethamphetamine (MDMA, "ecstasy") are rare in Austria, although the use of designer drugs has become quite common. This is the first published case of a fatal MDMA intoxication in Austria. A 19-year-old girl died after the consumption of ecstasy tablets in the apartment of a friend. Blood analysis gave a concentration of MDMA as 3.8 mg/L and traces of its metabolite MDA. Cannabinoids were found as well. This case shows that the consumption of MDMA, without physical stress, can lead to death.

Differences in the in vivo dynamics of neurotransmitter release and serotonin uptake after acute para-methoxyamphetamine and 3,4-methylenedioxymethamphetamine revealed by chronoamperometry

Illicit use of p-methoxyamphetamine (PMA) is rapidly increasing. However, little is known about the acute effects of PMA on neurotransmission in vivo. High-speed chronoamperometry was used to monitor neurotransmitter release and clearance in anesthetized rats after local application of PMA or 3,4-methylenedioxymethamphetamine (MDMA). In striatum, PMA caused less neurotransmitter release than MDMA. PMA-evoked release could be partially blocked by pre-treatment with a serotonin (5-HT) reuptake inhibitor, suggesting that evoked 5-HT release contributed to the electrochemical signal and was mediated by the 5-HT transporter (SERT). MDMA-evoked release was not blocked by a SERT inhibitor, suggesting that primarily DA was released. To study the effect of these amphetamines on clearance of 5-HT mediated specifically by the SERT, clearance of exogenously applied 5-HT was measured in the CA3 region of the hippocampus. In contrast to the striatum where 5-HT is cleared by both the SERT and the dopamine transporter (DAT), 5-HT is cleared primarily by the SERT in the CA3 region. This is also a region where neither PMA nor MDMA evoked release of neurotransmitter. The maximal inhibition of 5-HT clearance was greater after PMA than MDMA. These data demonstrate in vivo (1) brain region variability in the ability of PMA and MDMA to evoke release of neurotransmitter; (2) that clearance of 5-HT in the striatum is mediated by both the SERT and the DAT; (3) distinct differences in the amount and nature of neurotransmitter released in the striatum after local application of PMA and MDMA and (4) that PMA is a more efficacious inhibitor of 5-HT clearance in the hippocampus than MDMA. These fundamental differences may account for the more severe adverse reactions seen clinically after PMA, compared to MDMA.

Effects of 3,4-methylenedioxymethamphetamine (MDMA, ‘Ecstasy’) and para-methoxyamphetamine on striatal 5-HT when co-administered with moclobemide

3,4-Methylenedioxymethamphetamine (MDMA, "ecstasy") and para-methoxyamphetamine (PMA) are commonly used recreational drugs. PMA, often mistaken for MDMA, is reported to be more toxic in human use than MDMA. Both of these drugs have been shown to facilitate the release and prevent the reuptake of 5-hydroxytryptamine (5-HT, serotonin). PMA is also a potent inhibitor of monoamine oxidase type A (MAO-A), an enzyme responsible for the catabolism of 5-HT, and this characteristic may contribute to its increased toxicity. In humans, co-administration of MDMA with the reversible MAO-A inhibitor moclobemide has led to increased apparent toxicity with ensuing fatalities. In the present study, using microdialysis, we examined the effects of co-administration of MDMA and PMA with moclobemide on extracellular concentrations of 5-HT and 5-hydroxy indol acetic acid (5-HIAA) in the striatum of the rat. 5-HT-mediated effects on body temperature and behavior were also recorded. Rats were pretreated with saline or 20 mg/kg (i.p.) moclobemide and 60 min later injected with 10 mg/kg MDMA, PMA, or saline. Dialysate samples were collected every 30 min for 5 h and analyzed by HPLC-ED. Both MDMA and PMA produced significant increases in extracellular 5-HT concentrations (590% and 360%, respectively, P < 0.05). Rats treated with PMA and MDMA displayed significantly increased 5-HT-related behaviors (P < 0.05). Furthermore, only MDMA was capable of producing additional significant increases in 5-HT concentrations (980%, P < 0.05) when co-administered with moclobemide. These data suggest that co-administration of MDMA with moclobemide increases extracellular 5-HT and 5-HT-mediated behaviors and may cause increased 5-HT related toxicity similar to that reported with PMA.

Postmortem toxicology of drugs of abuse

Conducting toxicology on post-mortem specimens provides a number of very significant challenges to the scientist. The range of additional specimens include tissues such as decomposing blood and other tissues, hair, muscle, fat, lung, and even larvae feeding on the host require special techniques to isolate a foreign substance and allow detection without interference from the matrix. A number of drugs of abuse are unstable in the post-mortem environment that requires careful consideration when trying to interpret their significance. Heroin, morphine glucuronides, cocaine and the benzodiazepines are particularly prone to degradation. Moreover, redistributive process can significantly alter the concentration of drugs, particularly those with a higher tissue concentration than the surrounding blood. The designer amphetamines, methadone and other potent opioids will increase their concentration in blood post-mortem. These processes together with the development of tolerance means that no concentration of a drug of abuse can be interpreted in isolation without a thorough examination of the relevant circumstances and after the conduct of a post-mortem to eliminate or corroborate relevant factors that could impact on the drug concentration and the possible effect of a substance on the body. This article reviews particular toxicological issues associated with the more common drugs of abuse such as the amphetamines, cannabinoids, cocaine, opioids and the benzodiazepines.

IDENTIFICATION OF HUMAN CYTOCHROME P450 2D6 AS MAJOR ENZYME INVOLVED IN THEO-DEMETHYLATION OF THE DESIGNER DRUGP-METHOXYMETHAMPHETAMINE

p-Methoxymethamphetamine (PMMA) is a new designer drug, listed in many countries as a controlled substance. Several fatalities have been attributed to the abuse of this designer drug. Previous in vivo studies using Wistar rats had shown that PMMA was metabolized mainly by O-demethylation. The aim of the study presented here was to identify the human hepatic cytochrome P450 (P450) enzymes involved in the biotransformation of PMMA to p-hydroxymethamphetamine. Baculovirus-infected insect cell microsomes, pooled human liver microsomes (pHLMs), and CYP2D6 poor-metabolizer genotype human liver microsomes (PM HLMs) were used for this purpose. Only CYP2D6 catalyzed O-demethylation. The apparent K(m) and V(max) values in baculovirus-infected insect cell microsomes were 4.6 +/- 1.0 microM and 92.0 +/- 3.7 pmol/min/pmol P450, respectively, and 42.0 +/- 4.0 microM and 412.5 +/- 10.8 pmol/min/mg protein in pHLMs. Inhibition studies with 1 microM quinidine showed significant inhibition of the metabolite formation (67.2 +/- 0.6%; p < 0.0001), and comparison of the metabolite formation between pHLMs and PM HLMs revealed significantly lower metabolite formation in the incubations with PM HLMs (87.3 +/- 1.1%; p < 0.0001). According to these studies, CYP2D6 is the major P450 involved in O-demethylation of PMMA.

Screening for and validated quantification of amphetamines and of amphetamine- and piperazine-derived designer drugs in human blood plasma by gas chromatography/mass spectrometry

The classical stimulants amphetamine, methamphetamine, ethylamphetamine and the amphetamine-derived designer drugs MDA, MDMA ('ecstasy'), MDEA, BDB and MBDB have been widely abused for a relatively long time. In recent years, a number of newer designer drugs have entered the illicit drug market. 4-Methylthioamphetamine (MTA), p-methoxyamphetamine (PMA) and p-methoxymethamphetamine (PMMA) are also derived from amphetamine. Other designer drugs are derived from piperazine, such as benzylpiperazine (BZP), methylenedioxybenzylpiperazine (MDBP), trifluoromethylphenylpiperazine (TFMPP), m-chlorophenylpiperazine (mCPP) and p-methoxyphenylpiperazine (MeOPP). A number of severe or even fatal intoxications involving these newer substances, especially PMA, have been reported. This paper describes a method for screening for and simultaneous quantification of the above-mentioned compounds and the metabolites p-hydroxyamphetamine and p-hydroxymethamphetamine (pholedrine) in human blood plasma. The analytes were analyzed by gas chromatography/mass spectrometry in the selected-ion monitoring mode after mixed-mode solid-phase extraction (HCX) and derivatization with heptafluorobutyric anhydride. The method was fully validated according to international guidelines. It was linear from 5 to 1000 micro g l(-1) for all analytes. Data for accuracy and precision were within required limits with the exception of those for MDBP. The limit of quantification was 5 micro g l(-1) for all analytes. The applicability of the assay was proven by analysis of authentic plasma samples and of a certified reference sample. This procedure should also be suitable for confirmation of immunoassay results positive for amphetamines and/or designer drugs of the ecstasy type.

Dancing with "death": p-methoxyamphetamine overdose and its acute management

Para-methoxyamphetamine (PMA) is a substituted synthetic amphetamine used in the recreational drug scene. It is unusual because of the high incidence of significant morbidity and mortality in overdose. We report a case of PMA overdose in South Australia, and review our experience with the drug. We review the literature on PMA overdose and offer suggestions on the management of overdose with this dangerous drug.

Comparative effects of substituted amphetamines (PMA, MDMA, and METH) on monoamines in rat caudate: a microdialysis study

Paramethoxyamphetamine (PMA) is a methoxylated phenethylamine derivative that has been used illicitly in Australia since 1994. PMA is also becoming popular at rave parties in the United States. PMA raised concern when a series of fatalities resulted after its use in South Australia, where it was marketed as "ecstasy," which is the colloquial name for MDMA. In the present study, we evaluated the comparative neurotoxicity of substituted amphetamines in rats. Extracellular levels of dopamine (DA), 3,4-dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), serotonin (5-HT), and 5-hydroxyindoleacetic acid (5-HIAA) were assayed in the caudate of freely moving rats using microdialysis and HPLC-EC. Dialysates were assayed every 20 minutes for 4 hours after an intraperitoneal (i.p.) injection of PMA (2.5, 5, 10, 20 mg/kg), MDMA (10 and 20 mg/kg), or METH (2.5 mg/kg). METH produced a significant increase in extracellular DA (700%), and significant decreases in extracellular DOPAC and HVA (30% and 50%), with no detectable changes in either 5-HT or 5-HIAA. MDMA produced significant increases in DA (700% at 10 mg/kg and 950% at 20 mg/kg) and decreases in DOPAC (15% for both 10 and 20 mg/kg), and HVA (50% at 10 mg/kg and 35% at 20 mg/kg). MDMA also increased 5-HT (350% at 10, and 575% at 20 mg/kg), and decreased 5-HIAA to 60% for both dose levels. PMA produced no detectable increases in DA at dose levels of 2.5, 5, or 10 mg/kg, but significantly increased DA (975%) at a dose of 20 mg/kg. However, PMA significantly decreased DOPAC at all dose levels (75% at 2.5; 40% at 5; 30% at 10; 10% at 20 mg/kg), with comparable decreases in HVA at all dose levels. PMA also produced significant increases in 5-HT at 10 and 20 mg/kg (350% for both dose levels), with no detectable changes in 5-HT at 2.5 or 5 mg/kg. All dose levels of PMA significantly decreased 5-HIAA (50 to 70%). These data suggest that PMA, like MDMA and METH, is capable of producing dopaminergic and serotonergic neurotoxicity.

Effect of PMA optical isomers and 4-MTA in PMMA-trained rats

1-(4-Methoxyphenyl)-2-aminopropane (PMA) and its sulfur analog, 1-(4-methylthiophenyl)-2-aminopropane (4-MTA), have been misrepresented as the controlled substance analog, N-methyl-1-(3,4-methylenedioxyphenyl)-2-aminopropane (MDMA; "Ecstasy"). Because MDMA has been shown to produce both amphetamine-like and N-methyl-1-(4-methoxyphenyl)-2-aminopropane (PMMA)-like stimulus effects in rats, we examined S(+)PMA, R(-)PMA and 4-MTA in rats trained to discriminate either PMMA (1.25 mg/kg) or (+)amphetamine (1.0 mg/kg) from saline vehicle. The sulfur analog of PMMA (i.e., 4-MTMA) was also examined. The PMMA stimulus generalized to R(-)PMA (ED50=0.4 mg/kg), whereas S(+)PMA produced a maximum of 72% PMMA-appropriate responding. 4-MTA (ED50=0.3 mg/kg) also substituted for PMMA, but 4-MTMA produced a maximum of only 36% PMMA-appropriate responding. None of the four agents substituted for (+)amphetamine. Hence, like MDMA, R(-)PMA and 4-MTA are capable of producing PMMA stimulus effects in rats, but unlike MDMA, neither agent substituted for (+)amphetamine.

Preventing problems in Ecstasy users: reduce use to reduce harm

Increasing use of 3,4-methylenedioxymethamphetamine (MDMA, "Ecstasy") has been accompanied by concern about acute and possible long-term toxicity. This article discusses acute serious toxicity, chronic toxicity, and common problems associated with Ecstasy use, as well as the implications of these areas for prevention programs targeted at current Ecstasy users. The low incidence of serious adverse events in users creates difficulties for attempts to develop harm reduction recommendations. Many hypothesized risk factors for serious adverse events cannot be confirmed or denied and may not be associated with dramatic elevations in risk. Research on chronic toxicity in users provides strong evidence of neurophysiological changes and suggestive evidence of possible neurocognitive changes. Because these worrisome changes are clinically subtle, users may not be influenced by concerns of neurotoxicity. In contrast, common Ecstasy-related complaints are relatively well documented and have identified risk factors, including factors relating to extent of Ecstasy use (such as "binges"). Common complaints include modest acute and subacute adverse effects,some lasting several days, and problems in life. The apparent willingness of users to modify drug use and other behaviors to decrease these common problems could be used by harm reduction or other prevention programs to encourage users to decrease the extent of Ecstasy use.